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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for treatment of autism |
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spectrum disorders. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1355.001(3), Insurance Code, is amended |
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to read as follows: |
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(3) "Autism spectrum disorder" means: |
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(A) a neurobiological disorder or developmental |
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disability that significantly affects verbal communication, |
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nonverbal communication, and social interaction and that meets the |
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diagnostic criteria for autism spectrum disorder specified by the |
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Diagnostic and Statistical Manual of Mental Disorders, 5th edition, |
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or a later edition; or |
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(B) a diagnosis made using a previous edition of |
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the Diagnostic and Statistical Manual of Mental Disorders of |
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[includes] autism, Asperger's syndrome, or Pervasive Developmental |
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Disorder--Not Otherwise Specified. |
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SECTION 2. Section 1355.015, Insurance Code, is amended by |
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amending Subsections (a-1), (c), and (c-1) and adding Subsections |
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(a-2) and (c-2) to read as follows: |
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(a-1) At a minimum, a health benefit plan must provide |
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coverage for any medically necessary treatment of autism spectrum |
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disorder as provided by this section to an enrollee who is diagnosed |
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with autism spectrum disorder from the date of diagnosis[, only if |
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the diagnosis was in place prior to the child's 10th birthday]. |
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(a-2) For purposes of Subsection (a-1): |
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(1) "Medically necessary" means a service or product |
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that: |
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(A) addresses the specific needs of a patient; |
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(B) is provided for the purpose of screening for, |
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preventing, diagnosing, managing, or treating an illness, injury, |
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or condition, or the symptoms of that illness, injury, or |
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condition, including by minimizing the progression of an illness, |
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injury, condition, or symptom; |
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(C) is delivered in accordance with the generally |
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recognized independent standards of mental health and substance use |
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disorder care; |
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(D) is clinically appropriate in terms of type, |
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frequency, extent, site, and duration, as applicable, for the |
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service or product; and |
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(E) is not provided primarily for: |
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(i) the economic benefit of the health |
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benefit plan issuer or person who purchases the service or product; |
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or |
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(ii) the convenience of the patient, |
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treating physician, or other health care provider. |
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(2) "Generally recognized independent standards of |
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mental health and substance use disorder care" means a standard of |
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care and clinical practice that: |
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(A) is generally recognized by health care |
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providers practicing in the applicable clinical specialty, |
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including in psychiatry, psychology, clinical sociology, addiction |
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medicine, counseling, or behavioral health treatment; and |
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(B) is based on valid, evidence-based sources |
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reflecting generally accepted standards of mental health and |
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substance use disorder care, including: |
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(i) peer-reviewed scientific studies or |
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medical literature; and |
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(ii) the recommendation of a governmental |
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agency or relevant nonprofit health care provider professional |
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association or specialty society, including: |
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(a) patient placement criteria |
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promulgated by the National Library of Medicine; |
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(b) clinical practice guidelines |
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promulgated by the National Center for Complementary and |
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Integrative Health; |
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(c) the recommendation of a federal |
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governmental agency; and |
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(d) drug labeling approved by the |
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United States Food and Drug Administration. |
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(c) For purposes of Subsections [Subsection] (b) and (c-2), |
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"generally recognized services" may include services such as: |
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(1) evaluation and assessment services; |
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(2) applied behavior analysis; |
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(3) behavior training and behavior management; |
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(4) speech therapy; |
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(5) occupational therapy; |
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(6) physical therapy; or |
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(7) medications or nutritional supplements used to |
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address symptoms of autism spectrum disorder. |
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(c-1) The health benefit plan may [is] not require [required |
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to provide coverage under Subsection (b) for benefits for] an |
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enrollee to be evaluated for autism spectrum disorder more than |
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once every 10 years [of age or older for applied behavior analysis |
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in an amount that exceeds $36,000 per year]. |
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(c-2) The health benefit plan may not: |
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(1) prohibit or place a limitation on a health care |
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practitioner described by Subsection (b)(1) from performing an |
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evaluation or reevaluation, or soliciting a confirmation of |
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diagnosis of autism spectrum disorder from a primary care physician |
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or a diagnostician who has previously provided a diagnosis of |
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autism spectrum disorder for an enrollee; or |
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(2) restrict the setting in which generally recognized |
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services prescribed in relation to autism spectrum disorder are |
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provided to the enrollee, including assessments, evaluation, |
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therapeutic intervention, or observations, except for a setting in |
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which the enrollee qualifies for reimbursable services under the |
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state Medicaid program, including under the school health and |
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related services program. |
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SECTION 3. The changes in law made by this Act apply only to |
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a health benefit plan delivered, issued for delivery, or renewed on |
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or after January 1, 2024. A health benefit plan delivered, issued |
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for delivery, or renewed before January 1, 2024, is governed by the |
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law as it existed immediately before the effective date of this Act, |
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and that law is continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2023. |